Provider Demographics
NPI:1033190806
Name:CANDLEWOOD PHARMACY
Entity Type:Organization
Organization Name:CANDLEWOOD PHARMACY
Other - Org Name:CANDLEWOOD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTERANTUONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-746-2404
Mailing Address - Street 1:11 RT 37
Mailing Address - Street 2:BOX 8874
Mailing Address - City:NEW FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 RT 37
Practice Address - Street 2:BOX 8874
Practice Address - City:NEW FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06812
Practice Address - Country:US
Practice Address - Phone:203-746-2404
Practice Address - Fax:203-746-2269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1040333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0705244OtherOTHER ID NUMBER-COMMERCIAL NUMBER